Resilience, depressed mood,_and_menopausal.10

Menopause: The Journal of The North American Menopause SocietyVol. 21, No. 2, pp. 159/164DOI: 10.1097/gme.0b013e31829479bb* 2013 by The North American Menopause Society

Resilience, depressed mood, and menopausal symptoms inpostmenopausal women

Faustino R. Perez-Lopez, MD, PhD,1,2 Gonzalo Perez-Roncero, RN,1 Jose Fernandez-Inarrea, MD,3

Ana M. Fernandez-Alonso, MD, PhD,1,4 Peter Chedraui, MD, MSc,1,5 Placido Llaneza, MD, PhD,6

and for The MARIA (MenopAuse RIsk Assessment) Research Group

AbstractObjective: This study aims to assess resilience, depressed mood, and menopausal symptoms in postmenopausal

women.Methods: In this cross-sectional study, 169 postmenopausal women aged 48 to 68 years were asked to fill out the

Wagnild and Young Resilience Scale (WYRS), the Center for Epidemiologic Studies Depression Scale (CESD-10),the Menopause Rating Scale (MRS), and a questionnaire containing personal and partner sociodemographic data.

Results: The median [interquartile range] age of participating women was 54 [10.0] years. Among the women,55.6% had increased body mass index, 76.9% had a partner, 17.8% were current smokers, 14.2% had hypertension,25.4% used psychotropic drugs, and 13.0% used hormone therapy. Forty-five percent of the women had depressedmood (CESD-10 scores Q10), and 34.9% had severe menopausal symptoms (total MRS scores Q17). Less resilience(lower WYRS scores) correlated with depressed mood (higher CESD-10 scores) and severe menopausal symptoms(higher total, psychological, and urogenital MRS scores). Multiple linear regression analysis determined that WYRSscores positively correlated with exercising regularly and inversely correlated with CESD-10 scores (depressedmood). CESD-10 scores positively correlated with somatic and psychological MRS subscale scores and inverselycorrelated with WYRS scores (less resilience).

Conclusions: In this postmenopausal sample, depressed mood and participation in regular exercise correlate withlower and higher resilience, respectively. Depressed mood is associated with the severity of menopausal symptoms(somatic and psychological).

Key Words: Postmenopausal women Y Depressive mood Y Resilience Y Menopausal symptoms Y Center forEpidemiologic Studies Depression Scale Y Wagnild and Young Resilience Scale Y Menopause Rating Scale.

Menopausal transition is a time when physical, psy-chological, and social value changes take place, inturn affecting women_s health. Despite this, the

importance of comorbid conditions and individual personali-ties is still not clear.1<3 Psychological resilience is an indi-vidual_s capacity to prevent, minimize, or overcome stressful

situations imposed by life adversity.4<7 It is a measure of howindividuals cope with, overcome, or become positivelystrengthened by changes and challenges.8,9 Resilience is piv-otal to healthy aging, maintains well being, and has beencorrelated with mortality and longevity.10 Women who dis-play higher resilience may in fact have fewer menopausalcomplaints.11 Furthermore, complex relationships between de-pressive symptoms and resilience exist. Resilience, life satis-faction, perceived stress, and feelings of loneliness are notroutinely included in tools designed to assess menopausalsymptoms and related quality of life. These tools tend to spe-cifically address symptom frequency and severity, and physicaland emotional aspects among perimenopausal or postmeno-pausal women, as compared with premenopausal womenserving as controls.12<17

Although resilience is important for coping with meno-pause, updated studies assessing resilience, depressive symp-toms, andmenopausal symptoms, specifically in postmenopausalwomen, are still limited.5,11,18 Therefore, the aim of the presentstudy was to assess resilience, depressed mood, and meno-pausal symptoms among postmenopausal women.

Received February 4, 2013; revised and accepted March 25, 2013.

From the 1Red de Investigacion en Ginecologıa, Obstetricia y Reproduccion,Zaragoza, Spain; 2Departamento de Obstetricia y Ginecologıa, Universidadde Zaragoza, Zaragoza, Spain; 3Departamento de Obstetricia y Ginecologıa,Hospital de Cabuenes, Gijon, Asturias, Spain; 4Departamento de Obstetriciay Ginecologıa, Hospital Torrecardenas, Almerıa, Spain; 5Instituto deBiomedicina, Area de Investigacion para la Salud de la Mujer, Facultad deCiencias Medicas, Universidad Catolica de Santiago de Guayaquil, Gua-yaquil, Ecuador; and 6Departamento de Obstetricia y Ginecologıa, HospitalCentral de Asturias, Universidad de Oviedo, Oviedo, Spain.

Funding/support: None.

Financial disclosure/conflicts of interest: None reported.

Address correspondence to: Faustino R. Perez-Lopez, MD, PhD, De-partment of Obstetrics and Gynecology, University of Zaragoza Hos-pital Clınico, Domingo Miral s/n, Zaragoza 50009, Spain. E-mail:[email protected]

Menopause, Vol. 21, No. 2, 2014 159

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

METHODS

Study design and participantsThis was a cross-sectional study carried out at the Asturias

Central University Hospital (Oviedo, Spain) and the CabuenesHospital (Gijon, Spain), both affiliated with the Universityof Oviedo (Oviedo, Spain), where postmenopausal women(48-68 y) attending the outpatient clinics for their annual gyne-cological checkup were asked to fill out an itemized generalquestionnaire (personal and partner sociodemographic data),the Wagnild and Young Resilience Scale (WYRS), the Centerfor Epidemiologic Studies Depression Scale (CESD-10), andthe Menopause Rating Scale (MRS).16,19<24 Participants wereinformed of the study and its objectives. Those who chose toparticipate provided a written informed consent form. Womenwho were unable to verbalize an adequate understanding ofthe study, did not provide consent for participation, or hadpsychological or physical incapacity imposing difficultiesduring the interview were excluded. This research protocolwas reviewed and approved by the Asturias Ethical Commit-tee (Oviedo, Spain).

General surveyThe general questionnaire collected the following data on

women: age, parity, marital and partner status, educationallevel, place of residency, current height and weight (to calculatebody mass index [BMI]), engagement in regular exercise(yes/no), time since menopause, surgical menopause status,smoking habit, hypertension, and use of hormone therapy(HT), psychotropic drugs, or sleep-aiding drugs. Postmeno-pause status was defined as amenorrhea in the past 12 monthsor bilateral oophorectomy (surgical menopause). BMI wascalculated as body weight (kg) divided by height (m) squaredand categorized as low (G18.5 kg/m2), normal (18.5-24.9 kg/m2),or high (Q25 kg/m2). Women with high BMI were further cate-gorized as overweight (25-29.99 kg/m2) or obese (Q30 kg/m2).25

Data related to the partner were provided by the participatingwomen and included age, educational level, engagement inregular exercise (yes/no), alcohol abuse, and presence ofsexual dysfunction (erectile dysfunction, premature ejacula-tion, or both).

Wagnild and Young Resilience ScaleThe WYRS is a 14-item Likert-type scale used to assess

resilience status in various age groups and under differentconditions. Each item can be graded from B1[ (strongly dis-agree) to B7[ (strongly agree).20,21 Graded items are summedup to provide a total score. Although no cutoff value isavailable to define abnormality, lower scores are indicative ofless resilience.

Center for Epidemiologic Studies Depression ScaleCESD-10 is a 10-item questionnaire used to assess how in-

dividuals felt during the past week. This is a short version ofthe 20-item CESD tool.22<24 Each item can be graded accordingto a Likert scale: 0, rarely or none of the time (G1 d); 1, someor a little of the time (1-2 d); 2, occasionally or a moderateamount of time (3-4 d); 3, all the time (5-7 d). Items 5 and

8 are scored inversely. All graded items are summed up toprovide a total score. Scores of 10 or greater were used to de-fine depressed mood.23,24

Menopause Rating ScaleThe MRS assesses the presence and severity of menopausal

symptoms through 11 items grouped into three subscales: so-matic, psychological, and urogenital. Each item can be gradedas 0 (not present), 1 (mild), 2 (moderate), 3 (severe), or 4 (verysevere). Graded items within each subscale are summed up toprovide a total subscale score. The total MRS score is the sumof subscale scores.16,19 A total MRS score of 17 or more isdefined as severe.

Sample size calculationA minimal sample size of 160 participants was calculated,

assuming that 40% of participating women would presentlower resilience,11,19,20 with a 10% desired precision and a99% confidence level.

Statistical methodsPredictive Analytics Software version 17 (SPSS Inc,

Chicago, IL) was used to perform the analyses. Data arepresented as mean (SD), median [interquartile range], percen-tiles (25th-75th), percentages, coefficients, and 95% CI. Theinternal consistency of the instruments used (WYRS, CESD-10,and MRS) was assessed by computing Cronbach_s > co-efficients. Kolmogorov-Smirnov test was used to determine thenormality of data distribution. According to this, nonparametriccontinuous data were compared with Mann-Whitney U test(two independent samples) or Kruskal-Wallis test (various in-dependent samples). Student_s t test or analysis of variance wasused for parametric comparisons.

Spearman_s Q coefficients were calculated to determinecorrelations between WYRS, CESD-10, and MRS scores andvarious numeric variables (bivariate analysis). Multiple linearregression analysis was performed to obtain two independentmodels: the first model analyzes variables correlating withWYRS scores (resilience, dependent variable), and the secondmodel analyzes variables correlating with CESD-10 scores(depressed mood, dependent variable). These models wereconstructed from independent variables (woman and partner)achieving P e 0.10 during bivariate analysis. Entry of variablesinto the models was performed using a forward/backwardstepwise procedure. For all calculations, P G 0.05 was con-sidered statistically significant.

RESULTS

During the study period, a total of 205 postmenopausalwomen were invited to participate. Eleven (5.4%) declinedparticipation, and 25 (12.2%) provided incomplete data. Hence,169 women provided complete data for statistical analysis.The general characteristics of the participants and their part-ners are depicted in Table 1. The median [interquartile range]age of participating women was 54 years [10], with 82.8%residing in urban areas, 33.1% completing primary education,75.1% being married, and 76.9% currently having a partner.

160 Menopause, Vol. 21, No. 2, 2014 * 2013 The North American Menopause Society

PEREZ-LOPEZ ET AL


Regarding general health, 14.2% had hypertension, 55.6% hadincreased BMI (overweight or obese), and 33.1% engaged inregular exercise. Comorbidity, including gastric reflux, hypo-thyroidism, and dyslipidemia (the three most frequent), waspresent in 29.0% of women (data not shown in Table 1).Among the women, 10.7% had surgical menopause, and13.0% and 25.4% were taking HT and psychotropic drugs,

respectively. In addition, severe menopausal symptoms anddepressed mood were present in 34.9% and 45.0% of women,respectively.

Data on men were available for 76.9% of women whostated that they currently have a partner (n = 100/130). Themedian [interquartile range] age was 59 years [7.0]. Twenty-five percent of the women exercised regularly, 3.0% abusedalcohol, and 39.0% had primary education only. Erectiledysfunction was present in 17.0%, and premature ejaculationwas present in 3.0%.

A descriptive analysis ofMRS,WYRS, and CESD-10 scoresis depicted in Table 2. The computed Cronbach_s > coeffi-cients for CESD-10, WYRS, and MRS were 0.813, 0.893, and0.849, respectively. Spearman_s Q coefficients between tools(CESD-10, WYRS, and MRS) and other numeric variables aredepicted in Table 3. There was a significant inverse correlationbetween WYRS scores and depressed mood (higher CESD-10scores) and severe menopausal symptoms (higher total, psy-chological subscale, and urogenital subscale MRS scores).There was also a positive correlation between CESD-10 scores(more depressed mood) and MRS scores (total score and allsubscale scores).

Multiple linear regression analysis was used to obtain twofinal reduced best-fit models displaying variables correlatingwith WYRS and CESD-10 scores (Table 4). In the first model(explaining 22.7% of the total variance), WYRS scores in-versely correlated with depressed mood and positively corre-lated with women_s regular exercise. In the second model(explaining 53.2% of the total variance), CESD-10 scorespositively correlated with somatic and psychological MRSscores and inversely correlated with WYRS scores.

DISCUSSION

The present study aimed to assess resilience in a sample ofpostmenopausal women and to establish correlations with de-pressed mood and menopausal symptoms after controlling forseveral sociodemographic factors. The tools used in our studyhave been widely validated under different conditions in otherstudies, displaying high internal consistencies,5,6,11,16,20<24,26,27

in correlation with our results.Severe menopausal symptoms (as assessed with the MRS)

were present in one third of the participating women, despitethe relatively low rate of HT use (13%). HT use is particularlyinfrequent among Spanish women and those from other re-gions. This occurred basically because of the negative infor-mation on HT disseminated in the last decade after thepublication of the Women_s Health Initiative trial results.19,27,28

Three validated instruments were used in the present researchto render a more profound understanding of menopause-relatedresilience. Overall, upon bivariate analysis, WYRS scoresdisplayed significant correlations with depressive scores and allMRS scores (except for the somatic subscale). Depressivescores correlated with resilience scores and all MRS subscalescores (Table 3).

Resilience is the ability to be reinforced after overcominglife difficulties or stressing events. This ability has genetic,

TABLE 1. General characteristics of the participantsand their partners

Parameters

Women (n = 169)Age, y 54.0 [10.0]e50 55 (32.5)51-55 45 (26.6)56-60 40 (23.7)960 29 (17.2)

Parity 2.0 [1.0]Nulliparous 33 (19.5)1-2 114 (67.5)Q3 22 (13.0)

Marital statusMarried 127 (75.1)Single 17 (10.1)Widowed 9 (5.3)Divorced 13 (7.7)Cohabiting 3 (1.8)Currently has a partner 130 (76.9)

Highest educational level achievedPrimary school 56 (33.1)High school 77 (45.6)University 36 (21.3)

Urban residency 140 (82.8)Body mass index, kg/m2 25.1 [5.9]Low 2 (1.2)Normal 73 (43.2)Overweight 63 (37.3)Obese 31 (18.3)

Engages in regular exercise 56 (33.1)Current smoker 30 (17.8)Hypertension 24 (14.2)Time since menopause onset, y 3.0 [8.0]G5 92 (54.4)5-7 77 (45.6)Q8 45 (26.6)

Surgical menopause 18 (10.7)Depressed mood (CESD-10 score Q10) 76 (45)Severe menopausal symptoms (total MRS score Q17) 59 (34.9)Current use of HT 22 (13.0)Current use of psychotropic drugs 43 (25.4)Current use of sleep-aiding drugs 64 (37.9)

Partner data (n = 100)Age, y 59.0 [7.0]e50 5 (5.0)51-55 21 (21.0)56-60 35 (35.0)61-65 29 (29.0)965 10 (10.0)

Highest educational level achievedPrimary school 39 (39.0)High school 44 (44.0)University 17 (17.0)

Engages in regular exercise 25 (25.0)Alcohol abuse 3 (3.0)Erectile dysfunction 17 (17.0)Premature ejaculation 3 (3.0)

Data are presented as n (%) or median [interquartile range].CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Meno-pause Rating Scale; HT, hormone therapy.


RESILIENCE IN POSTMENOPAUSAL WOMEN


neural, health, learning, economic, stress, and social compo-nents.3<6,11,18,29,30 Menopausal transition is a long process thatis lived, in many cases, with negative feelings and lack ofsupport. Therefore, a resilient woman can better cope withadversity. However, assessing all the components of resilienceis not easy. Many tools assess indirect measures of resil-ience such as self-esteem, sense of coherence, loneliness, orhappiness.26,30<32 The WYRS, on the other hand, displayshigh measures of consistency and correlation with life satis-faction scales.4,20,21

Few studies have analyzed resilience in middle-aged women,specifically postmenopausal women. In a large female Germansample (18-92 y), life satisfaction was associated with youngerage, resilience, employment status, higher household income,having a partner, lack of anxiety and depression, good self-esteem, and religious affiliation.5 In this population, there was asignificant reduction of resilience between the ages of 61 and70 years (most pronounced after 70 y). Resilience positivelycorrelated with life satisfaction and self-esteem and inverselycorrelated with anxiety and depression.

In a previous study of middle-aged Ecuadorian women,lower WYRS scores (less resilience) correlated with more se-vere hot flushes.11 Duffy et al18 studied factors associated withresilience and vulnerability to hot flushes and night sweatsduring the menopausal transition in a female Scottish sample.Women resilient to hot flushes had previously not been both-ered by their menstrual periods, did not experience somaticsymptoms or night sweats, and perceived their symptomsas having low consequences on their lives. Those vulnerableto hot flushes had children, had high BMI, reported nightsweats, and perceived their symptoms as having high life

consequences. Women resilient to night sweats were non-smokers, did not have sleep difficulties, were not treated forpsychological symptoms, and perceived their menopausal symp-toms as having low life consequences. Those vulnerable to nightsweats had lower education, had previously been bothered bytheir menstrual periods, had below-average physical health,reported musculoskeletal symptoms and hot flushes, and per-ceived their menopausal symptoms as having high life con-sequences. In our study, although WYRS scores displayedsignificant bivariate correlations with all MRS scores (exceptfor the somatic subscale), no correlation was found betweenWYRS scores and any of the MRS scores, interestingly, aftermultivariate linear regression analysis.

CESD-10 is a validated instrument for detecting depressedmood, which accounted for 45.0% of our postmenopausalpopulation. Our multivariate analysis found that resiliencewas inversely related to depressive mood (higher CESD-10scores) and positively related to exercising regularly. Reportsindicate that the prevalence of depression is higher in womenthan in men and tends to increase as women age. The causalrole of this increaseVwhether related to age, progressivehormonal decrease, or bothVis still a matter of controversy.33

Using the long version of CESD in an 8-year longitudinalstudy, Freeman et al34 demonstrated that total CESD scores of16 or higher (depressed mood) and depressive disorders were,respectively, 4 and 2.5 times more likely to occur during themenopausal transition as compared with the premenopausalyears. In a middle-aged and multiethnic female sample, Woodsand Mitchell35 used CESD and other tools to develop a multi-dimensional model for explaining depressed mood. Three as-pects were identified as correlating with depressed mood:

TABLE 2. Descriptive analysis of MRS, WYRS, and CESD-10 scores (n = 169)

MRS (> = 0.849)a

WYRS (> = 0.893)a CESD-10 (> = 0.813)aTotal Somatic Psychological Urogenital

Mean 13.9 5.3 5.1 3.4 77.7 9.3Median 13.0 5.0 5.0 3.0 79.0 8.025th-75th percentiles 8.0-19.0 3.0-7.0 2.0-7.0 1.0-5.0 70.0-87.0 5.0-12.5Interquartile range 11.0 4.0 5.0 4.0 17.0 7.5

MRS, Menopause Rating Scale; WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale.aValues in parentheses represent the computed Cronbach’s > coefficient for the scale.

TABLE 3. Spearman_s Q coefficients obtained between tool scores and various numeric variables

WYRS CESD-10

MRS

Total Somatic Psychological Urogenital

Age j0.069 0.065 0.177 0.252 0.086 0.146P 0.370 0.404 0.021 0.001 0.267 0.058Parity 0.059 0.031 0.107 0.135 0.007 0.142P 0.449 0.689 0.165 0.079 0.927 0.065Body mass index j0.069 0.133 0.107 0.166 0.101 j0.007P 0.371 0.085 0.166 0.031 0.190 0.932WYRS Y j0.432 j0.248 j0.143 j0.295 j0.157P G0.001 0.001 0.063 G0.001 0.042CESD-10 Y Y 0.610 0.487 0.642 0.346P G0.001 G0.001 G0.001 G0.001

WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Menopause Rating Scale.


PEREZ-LOPEZ ET AL


menopausal transition, health status, and stressful life context.The latter was considered the most important factor, whereashealth status had a direct effect and an indirect effect throughstress, and menopausal changes had low explanatory power. Alarge number of neurobiological and psychosocial factors areassociated with depression and resilience. Positive psychoso-cial factors, such as optimism, humor, cognitive flexibility, so-cial support, role models, coping style, and capacity to recover,are reduced in depressed individuals, which may explain theinverse correlation between resilience and depression found inour study. It is probable that neurobiological changes associatedwith depressive mood may secondarily affect resilience capac-ity36 orVseen the other way aroundVthat less resilient personsmay be more vulnerable to developing depression. Furtherresearch may indeed give insights into determining which iscause and which is consequence. Cognitive vulnerable indivi-duals have a severe risk of losing resilience because of de-pression, whereas social support and positive life events mayenhance their resilience.35 Therefore, cognitive education aimedat highlighting positive experiences during menopause mayboost resilience. It is interesting to recall that our populationdisplayed comorbid conditions (hypertension and sleep disor-ders) that may also contribute to the alteration of the neuro-biology of resilience and depression in labile women. A stressfullife context and associated issues may be important determi-nants of depressed mood. It has been reported that bad healthstatus has a direct effect on mood and an indirect effect on per-ceived stress, whereas menopausal changes have low power atexplaining depressive mood.33,35

Our regression model found that women who exercisedregularly displayed higher resilience. In one study, low spiri-tuality among individuals with depression and anxiety wasrevealed as a leading predictor of lower resilience, and lessfrequent exercise was associated with moderate resilience.37

Our results seem to suggest that exercising may contribute toincreased resilience and may improve treatment responseamong those who display depressed mood. This may in factbe true for those women who display higher BMI (who mayengage in less exercises). Unfortunately, our regression modeldid not find a correlation between resilience and depressivescores and BMI. Nevertheless, we have previously reported11

that women with higher abdominal circumference (obesity)display lower resilience. Hence, in this high-risk group, ex-ercise may have a positive impact on mood and resilience. In

any case, further studies are needed to delineate the separateinfluences of exercise intensity and exercise-related bodychanges associated with both depressed mood and resilience.

The regressionmodel for CESD-10 scores in our study founda significant and positive correlation between depressive scoresand menopausal somatic and psychological symptoms. This isin agreement with our previous research in which middle-agedwomen (premenopausal, perimenopausal, and postmenopausal)displayed a high prevalence of depressed mood in correlationwith more severe menopausal symptoms (somatic and psycho-logical) assessed with the same MRS.38 It is very well knownthat estradiol deprivation in postmenopausal women may in-crease depressive39 and menopausal1,2,28 symptoms.

Finally, the cross-sectional design, which does not allow forthe determination of causality for neither resilience nor de-pressed mood, is a limitation of this study. Although surveyingonly postmenopausal women does not allow for an analysis ofthe effects of age or menopause status on resilience or depres-sion status, selecting them (who may in fact be consulting formorbidity) from a gynecological outpatient service or a singleSpanish site does not allow for a generalization of results to therest of the Spanish population. Other potential drawbacks in-clude not assessing exercise intensity and finding moderateQ values upon bivariate analysis. Despite all the aforementionedlimitations, there have been few reports addressing resilienceduring the menopausal transition and even fewer studiesreporting specifically on postmenopausal women. Hence, to thebest of our knowledge, the present study seems to be among thefew studies reported to date.

More studies that analyze psychosocial and sociodemographicfactors, using resilience scales, among middle-aged women(including premenopausal, perimenopausal, and postmeno-pausal women) are needed.

CONCLUSIONS

In this postmenopausal female sample, depressed mood andparticipation in regular exercise correlate with lower and higherresilience, respectively. Depressed mood is associated with theseverity of menopausal symptoms, specifically somatic andpsychological symptoms. Although these correlations do notexplain causality, they do, however, highlight the need to in-clude resilience, mood, and other life satisfaction aspects in thedesign of future tools assessing menopausal symptoms.

TABLE 4. Factors correlating with WYRS and CESD-10 scores: multiple linear regression analysis

Factors A SE 95% CI t P

Model for WYRS scores (n = 169)Total CESD-10 score j0.911 0.148 j1.204 to j0.617 j6.133 G0.001Regular exercise 2.439 0.984 0.496 to 4.382 2.478 0.014r2 = 0.237; adjusted r2 = 0.227; P = 0.014

Model for CESD-10 scores (n = 169)Total WYRS score j0.130 0.026 j0.181 to j0.079 j5.007 G0.001MRS somatic score 0.463 0.141 0.184 to 0.741 3.280 0.001MRS psychological score 0.752 0.117 0.521 to 0.982 6.422 G0.001r2 = 0.541; adjusted r2 = 0.532; P G 0.001

WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Menopause Rating Scale.


RESILIENCE IN POSTMENOPAUSAL WOMEN


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